Home-based therapy programmes for upper limb functional recovery following stroke

A home-based hand rehabilitation platform for hemiplegic patients after stroke: A feasibility study

Background

Patients with stroke often experience weakened upper limbs, making daily tasks difficult to perform. Although rehabilitation devices are available, patients often relapse post-discharge due to insufficient practice. We present a home-based hand telerehabilitation intervention using the iManus™ platform comprising a sensorized glove, a mobile app for the patients, and a therapist portal for monitoring patient progress.

Objectives

This research aimed to examine the feasibility, safety, and effectiveness of a home-based telerehabilitation intervention in improving hand function for individuals with mild stroke. A qualitative approach was also used to explore users' experiences, perceived benefits, and challenges associated with using the platform in a home setting.

Methods

In this single-case study, we delivered a hand telerehabilitation intervention to a chronic stroke patient with impaired hand function using the iManus™ platform. The intervention consisted of 40 home sessions over eight weeks. We assessed feasibility through user adherence and feedback obtained using a System Usability Scale (SUS) and a semi-structured interview with the participant and their informal caregiver. Safety was evaluated by monitoring pain levels using the Visual Analog Scale (VAS), and efficacy was determined by observing the changes in the fingers' range of motion using the iManus™ platform and clinical outcomes measures, namely the Fugl-Meyer Assessment (FMA) and Jebsen Taylor Hand Function Test (JTHFT).

Results

Our participant completed all the assigned sessions, with each averaging 20 min. Usability scored 77.5 out of 100 on the SUS. User feedback from the interviews revealed improved mobility and control over therapy as benefits, indicating room for improvement in the intervention's adaptability and functionality. During the intervention, the participant noted no pain increase, and the telerehabilitation platform recorded range of motion improvements for all finger and wrist joints, excluding wrist extension. The FMA scores were 43 at T0, 53 at T1, and 56 at T2, while the JTHFT scores were 223 at T0, 188 at T1, and 240 at T2.

Conclusions

This single case study demonstrated the preliminary feasibility, safety, and efficacy of a novel home-based hand intervention for stroke survivors. The participant showed improved hand functions, good adherence to the program, and reported satisfaction with the intervention. However, these results are based on a single-case study, and further large-scale studies are needed before any generalization is recommended.

Perspectives on content and delivery of the ABLE 1.0 intervention programme

BACKGROUND

The occupational therapy intervention programme ABLE 1.0 was designed to enhance the ability to perform activities of daily living in persons living with chronic conditions. There is a need to determine if content and delivery of the ABLE 1.0 are acceptable among occupational therapists (OTs) and clients after having delivered or received the programme, respectively.

OBJECTIVES

The paper reports on evaluation of content and delivery of the ABLE 1.0 among OTs and clients. This, in terms of acceptability of intervention in principle, and perceived value, benefits, harms, or unintended consequences of the intervention.

MATERIAL AND METHODS

Qualitative semi-structured interviews were conducted with OTs having delivered and clients having received ABLE 1.0 in a Danish municipality. Content analysis was performed.

FINDINGS

Two OTs and three clients participated. Analyses revealed six categories related to content and delivery; 'Overall perception of the programme'; 'Potential for implementation'; 'Evaluation, goal setting and clarification of reasons for ADL task performance problems'; 'Intervention: compensatory solutions'; 'Format and duration' and 'Preconditions for delivery'.

CONCLUSIONS AND SIGNIFICANCE

The findings provided valuable information used for further development of the ABLE programme.

Task-specific training versus usual care to improve upper limb function after stroke: the "Task-AT Home" randomised controlled trial protocol

Background

Sixty percent of people have non-functional arms 6 months after stroke. More effective treatments are needed. Cochrane Reviews show low-quality evidence that task-specific training improves upper limb function. Our feasibility trial showed 56 h of task-specific training over 6 weeks resulted in an increase of a median 6 points on the Action Research Arm test (ARAT), demonstrating the need for more definitive evidence from a larger randomised controlled trial. Task-AT Home is a two-arm, assessor-blinded, multicentre randomised, controlled study, conducted in the home setting.

Aim

The objective is to determine whether task-specific training is a more effective treatment than usual care, for improving upper limb function, amount of upper limb use, and health related quality of life at 6 weeks and 6 months after intervention commencement. Our primary hypothesis is that upper limb function will achieve a ≥ 5 point improvement on the ARAT in the task-specific training group compared to the usual care group, after 6 weeks of intervention.

Methods

Participants living at home, with remaining upper limb deficit, are recruited at 3 months after stroke from sites in NSW and Victoria, Australia. Following baseline assessment, participants are randomised to 6 weeks of either task-specific or usual care intervention, stratified for upper limb function based on the ARAT score. The task-specific group receive 14 h of therapist-led task-specific training plus 42 h of guided self-practice. The primary outcome measure is the ARAT at 6 weeks. Secondary measures include the Motor Activity Log (MAL) at 6 weeks and the ARAT, MAL and EQ5D-5 L at 6 months. Assessments occur at baseline, after 6 weeks of intervention, and at 6 months after intervention commencement. Analysis will be intention to treat using a generalised linear mixed model to report estimated mean differences in scores between the two groups at each timepoint with 95% confidence interval and value of p.

Discussion

If the task-specific home-based training programme is more effective than usual care in improving arm function, implementation of the programme into clinical practice would potentially lead to improvements in upper limb function and quality of life for people with stroke.

Clinical Trial Registration

ANZCTR.org.au/ACTRN12617001631392p.aspx.

A Sensor-Based Feedback Device Stimulating Daily Life Upper Extremity Activity in Stroke Patients: A Feasibility Study

This study aims to evaluate the feasibility and explore the efficacy of the Arm Activity Tracker (AAT). The AAT is a device based on wrist-worn accelerometers that provides visual and tactile feedback to stimulate daily life upper extremity (UE) activity in stroke patients.

METHODS

A randomised, crossover within-subject study was conducted in sub-acute stroke patients admitted to a rehabilitation centre. Feasibility encompassed (1) adherence: the dropout rate and the number of participants with insufficient AAT data collection; (2) acceptance: the technology acceptance model (range: 7-112) and (3) usability: the system usability scale (range: 0-100). A two-way ANOVA was used to estimate the difference between the baseline, intervention and control conditions for (1) paretic UE activity and (2) UE activity ratio.

RESULTS

Seventeen stroke patients were included. A 29% dropout rate was observed, and two participants had insufficient data collection. Participants who adhered to the study reported good acceptance (median (IQR): 94 (77-111)) and usability (median (IQR): 77.5 (75-78.5)-). We found small to medium effect sizes favouring the intervention condition for paretic UE activity (η²G = 0.07, p = 0.04) and ratio (η²G = 0.11, p = 0.22).

CONCLUSION

Participants who adhered to the study showed good acceptance and usability of the AAT and increased paretic UE activity. Dropouts should be further evaluated, and a sufficiently powered trial should be performed to analyse efficacy.

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Effectiveness of home-based upper limb rehabilitation in stroke survivors: A systematic review and meta-analysis

Background

Home-based training is an alternative option to provide intensive rehabilitation without costly supervised therapy. Though several studies support the effectiveness of home-based rehabilitation in improving hemiparetic upper limb function in stroke survivors, a collective evaluation of the evidence remains scarce.

Objectives

This study aims to determine the effects of home-based upper limb rehabilitation for hemiparetic upper limb recovery in stroke survivors.

Methods

The databases of the Cochrane Library, MEDLINE, CINAHL, and Web of Science were systematically searched from January 2000 to September 2020. Only randomized, controlled, and cross-over trials that evaluated the effects of home-based upper limb interventions were selected. The Pedro scale was used to assess the methodological quality of the studies. A meta-analysis of the upper limb function outcomes was performed by calculating the mean difference/standardized mean difference using a fixed/random effect model.

Results

An initial search yielded 1,049 articles. Twenty-six articles were included in the review. The pooled evidence of the meta-analysis showed that home-based upper limb intervention was more effective in improving upper limb function [SMD: 0.28, 95% CI (0.12, 0.44), I² = 0%, p < 0.001, fixed effect model] than conventional therapy. When comparing two types of home-based interventions, subgroup analysis revealed that home-based technology treatment—electrical stimulation—provided more significant improvement in upper limb function than treatment without the use of technology (SMD: 0.64, 95% CI (0.21, 1.07), I² = 0%, p = 0.003, random effect model).

Conclusion

The beneficial effects of home-based upper limb interventions were superior to conventional therapy in improving function and perceived use of the hemiparetic upper limb in daily activities. Among the home-based interventions, home-based electrical stimulation seemed to provide the most optimal benefits.

New technologies promoting active upper limb rehabilitation after stroke: an overview and network meta-analysis

INTRODUCTION

The primary aim of this work was to summarize and compare the effects of active rehabilitation assisted by new technologies (virtual reality [VR], robot-assisted therapy [RAT] and telerehabilitation [TR)) on upper limb motor function and everyday living activity during the subacute and chronic phases of stroke. The secondary aims were to compare the effects of these technologies according to the intervention design (in addition to or in substitution of conventional therapy), the duration of active rehabilitation and the severity of patients' motor impairments.

EVIDENCE ACQUISITION

Several databases, namely PubMed, Scopus, Embase and Cochrane Library, were searched. Studies were included if they were meta-analyses with a moderate to high level of confidence (assessed with AMSTAR-2) that compared the effects of a new technology promoting active rehabilitation to that of a conventional therapy program among patients with stroke. Network meta-analyses were conducted to compare the effects of the new technologies.

EVIDENCE SYNTHESIS

Eighteen different meta-analyses were selected and fifteen included in the quantitative analysis. In total these 15 meta-analyses were based on 189 different randomized controlled trials. VR (SMD≥0.25; P<0.05), RAT (SMD≥0.29; P≤0.29) and TR (SMD≥-0.08; P≤0.64) were found to be at least as effective as conventional therapy. During the subacute phase, RAT's greatest effect was observed for patients with severe-moderate impairments whereas VR and TR's greatest effects were observed for patients with mild impairments. During the chronic phase, the highest effects were observed for patients with mild impairments, for all studies technologies. Network meta-analyses showed that VR and RAT were both significantly superior to TR in improving motor function during the chronic phase but revealed no significant difference between VR, RAT and TR effectiveness on both motor function (during the subacute phase) and activity (during both chronic and subacute phase).

CONCLUSIONS

This overview provides low-to-moderate evidence that rehabilitation assisted with technologies are at least as effective as conventional therapy for patients with stroke. While VR and RAT seem to be more efficient during the subacute phase, all technologies seem to be as efficient as one another in the chronic phase.

Rehabilitation efficacy comparison of virtual reality technology and computer-assisted cognitive rehabilitation in patients with post-stroke cognitive impairment: A network meta-analysis

OBJECTIVE

Virtual reality (VR) and computer-assisted cognitive rehabilitation (CACR) are two emerging rehabilitation therapies for stroke patients. The aim of this study was to compare the rehabilitation efficacy of these two treatments for patients with post-stroke cognitive impairment (PSCI).

METHODS

A network search of Embase, Web of Science, PubMed, Cochrane Library, VIP, WanFang Data, and CNKI databases was performed from their inception to February 2022 for screening randomized controlled trials related to VR and CACR in the treatment of PSCI. The quality of the included studies was assessed using the Cochrane risk bias assessment tool. The primary outcomes of the included studies contained at least one of the following clinical outcome measures: Mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA). After screening the literature, assessing the quality and extracting the data, a network meta-analysis was performed with STATA software.

RESULTS

A total of 21 randomized controlled trials were included, including 1,047 patients. The results of network meta-analysis showed that under MMSE index, VR group (p = 0.067) and CACR group (p = 0.054) tended to be superior to CT group, but it was not significant. Both the VR (p = 0.024) and CACR (p < 0.001) groups had significantly better outcomes compared to the conventional therapy group in terms of MoCA. The ranking results under both indicators showed that CACR had the best treatment effect, followed by VR.

CONCLUSION

In general, VR and CACR have superior efficacy compared with conventional therapy, in which CACR may be the best treatment option.

Feasibility of an individualised, task-oriented, video-supported home exercise programme for arm function in patients in the subacute phase after stroke: protocol of a randomised controlled pilot study

INTRODUCTION

Stroke rehabilitation guidelines suggest a high-frequency task-oriented training at high intensity. A targeted and self-paced daily training with intermittent supervision is recommended to improve patients' self-management and functional output. So far, there is conflicting evidence concerning the most effective home-training delivery method.

METHODS AND ANALYSIS

The purpose of this pilot study is to compare the feasibility and preliminary effects of task-oriented home-exercises in patients in the subacute stage after stroke. Twenty-four patients will be randomised (1:1) to a Video group (a) or Paper group (b) of an individualised, task-oriented home-training (50 min, 6×/week, for 4 weeks) based on Wulf and Lewthwaite's Optimizing Performance Through Intrinsic Motivation and Attention for Learning theory of motor learning. Patient-relevant goals will be identified using Goal Attainment Scaling and exercises progressively adapted. Semistructured interviews and a logbook will be used to monitor adherence, arm use and acceptability. Primary outcome will be the feasibility of the methods and a full-scale trial employing predefined feasibility criteria (recruitment, retention and adherence rates, patients' satisfaction with the home-exercise programme and their progress, affected hand use and acceptance of the intervention). Assessed at baseline, post intervention and 4-week follow-up, secondary outcomes include self-perceived hand and arm use, actual upper extremity function and dexterity, hand strength, independence in activities of daily living and health-related quality of life. Interview data will be analysed using qualitative content analysis. Medians (ranges) will be reported for ordinal data, means (SD) for continuous and frequency (percentage) for nominal data.

ETHICS AND DISSEMINATION

This study follows the Standard Protocol Items: Recommendations for Interventional Trials-Patient-Reported Outcome (PRO) Extension guideline. Ethical approval was received from the Ethics Committee of the Medical University of Innsbruck, Austria (1304/2020). Written informed consent will be obtained from all participants prior to data collection. Study results will be disseminated to participating patients, patient organisations, via the clinic's homepage, relevant conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS-ID: DRKS00023395.Study protocol, second revision, 5 December 2021.

Home Activity-based Interventions for the Neurologically Impaired Upper Extremity: A Scoping Review

Background:

Activity-based therapy (ABT) for the upper extremity (UE) enables neurologic recovery with tasks that are functional, intense, and highly repetitive. A large proportion of rehabilitation occurs in the home and there is a gap in literature on the application of ABT within the home. The objective of this scoping review was to describe ABT in the home-setting for the neurologically-impaired UE.

Methods:

A systematic scoping review included searches of: MEDLINE, CINAHL, Cochrane, and OTSeeker.

Results:

A systematic search yielded 51 final studies. About 61% of ABT studies were exclusively within the home, others included outpatient visits (37%). Telerehabilitation was used in 37% of the studies with live-video and store forward techniques equally represented. ABT supported by technology was used in 61% of studies. Dosing of intervention ranged from 7 to 120 hours, with a mean of 34.5 hours of practice. Adherence with intended dosing was reported in 27% of studies and subjects completed a mean of 86% of the intended practice time. Sixty-seven percent of studies reported some degree of practice without therapist supervision.

Conclusions:

The results showed wide variability in the intervention methods, dosing and technology used in homebased settings. The high rate of adherence with dosing is encouraging for the application of homebased neurologic UE interventions. This scoping review highlights feasibility of UE ABT within the home and need for further research.

Longer-term health and social care strategies for stroke survivors and their carers: the LoTS2Care research programme including cluster feasibility RCT

Background

It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified.

Objectives

The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations).

Design

Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales.

Setting

The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales.

Participants

Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services.

Data sources

Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified.

Intervention

Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks.

Results

A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains.

Conclusions

We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation.

Future work

Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation.

Trial registration

Current Controlled Trials ISRCTN38920246.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Dynamic hand orthoses for the recovery of hand and arm function in adults after stroke: A systematic review and meta-analysis of randomised controlled trials

Background: Repetitive, functional-based rehabilitation is recommended after stroke. However, impaired active digital extension is common after stroke, which limits functional-based rehabilitation and recovery. Non-robotic dynamic hand orthoses (DHOs) may address this.Objectives: We did a systematic review and meta-analysis to determine whether non-robotic DHOs improve upper limb recovery after stroke in comparison to i)placebo or no intervention and ii)usual care.Methods: We followed PRISMA guidelines. We included randomized controlled trials (RCTs) assessing upper limb recovery associated with the use of non-robotic DHOs in adults after stroke. Outcomes of interest were functional upper limb movement and activities of daily living.We performed searches on 27 September 2019 in 10 bibliographic databases including Cochrane Stroke Groups Specialized Trials Register and Cochrane Central Register of Controlled Trials. We also searched gray literature and citations from included studies.Two reviewers independently screened abstracts and full text, extracted data and assessed risk of bias using a Cochrane risk of bias tool.Results: We reviewed 7225 titles and included four studies involving 56 randomized participants, all with a high risk of bias. A positive effect in favor of non-robotic DHOs was observed for two outcomes; upper limb function (mean difference (MD) 6.23, 95% confidence interval (CI) 0.28-12.19 (p = 0.04)) and dexterity (MD 2.99, 95% CI 0.39-5.60 (p = 0.02).Conclusions: The results are encouraging but included studies were small with high risk of bias meaning there is currently insufficient evidence that non-robotic DHOs improve upper limb recovery after stroke.Review Registration: PROSPERO, CRD42020179180. Registered on 20 May 2020.

Effects of home-based mirror therapy and cognitive therapeutic exercise on the improvement of the upper extremity functions in patients with severe hemiparesis after a stroke: a protocol for a pilot randomised clinical trial

INTRODUCTION

Neuroplasticity is defined as the capacity of the brain to reorganise new neuronal pathways. Mirror therapy (MT) and cognitive therapeutic exercise (CTE) are two neurorehabilitation techniques based on neuroplasticity and designed to improve the motor functions of the affected upper extremity in patients with severe hemiparesis after a stroke. Home-based interventions are an appropriate alternative to promote independence and autonomy. The objective of this study is to evaluate which of these techniques, MT and CTE, combined with task-oriented training, is more effective in functional recovery and movement patterns of the upper extremities in patients with severe hemiparesis after a stroke.

METHODS AND ANALYSIS

This is a home-based, single-blind, controlled, randomised clinical trial with three parallel arms, including 154 patients who had a stroke aged above 18 years. The primary outcome will be the functionality of the affected upper extremity measured using the Fugl-Meyer Assessment. Secondary variables will include cognitive performance, emotional state, quality of life and activities of daily living. During 6 weeks, one of the intervention groups will receive a treatment based on MT and the other one on CTE, both combined with task-oriented training. No additional interventions will be provided to the control group. To assess the progress of patients who had a stroke in the subacute phase, all variables will be evaluated at different visits: initial (just before starting treatment and 4 weeks post-stroke), post-intervention (6 weeks after initial) and follow-up (6 months).

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board (CEIm-2.134/2.019) and registered at ClinicalTrials.gov (NCT04163666). The results will be disseminated through open-access peer-reviewed journals, conference presentation, broadcast media and a presentation to stakeholders. These study results will provide relevant and novel information on effective neurorehabilitation strategies and improve the quality of intervention programmes aimed at patients after a stroke.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT04163666).

Home-based rehabilitation using a soft robotic hand glove device leads to improvement in hand function in people with chronic spinal cord injury:a pilot study

BACKGROUND

Loss of hand function following high level spinal cord injury (SCI) is perceived as a high priority area for rehabilitation. Following discharge, it is often impractical for the specialist care centre to provide ongoing therapy for people living with chronic SCI at home, which can lead to further deterioration of hand function and a direct impact on an individual's capability to perform essential activities of daily living (ADL).

OBJECTIVE

This pilot study investigated the therapeutic effect of a self-administered home-based hand rehabilitation programme for people with cervical SCI using the soft extra muscle (SEM) Glove by Bioservo Technologies AB.

METHODS

Fifteen participants with chronic cervical motor incomplete (AIS C and D) SCI were recruited and provided with the glove device to use at home to complete a set task and perform their usual ADL for a minimum of 4 h a day for 12 weeks. Assessment was made at Week 0 (Initial), 6, 12 and 18 (6-week follow-up). The primary outcome measure was the Toronto Rehabilitation Institute hand function test (TRI-HFT), with secondary outcome measures including pinch dynamometry and the modified Ashworth scale.

RESULTS

The TRI-HFT demonstrated improvement in hand function at Week 6 of the therapy including improvement in object manipulation (58.3 ±3.2 to 66.9 ±1.8, p ≈ 0.01), and palmar grasp assessed as the length of the wooden bar that can be held using a pronated palmar grip (29.1 ±6.0 cm to 45.8 ±6.8 cm, p <0.01). A significant improvement in pinch strength, with reduced thumb muscle hypertonia was also detected. Improvements in function were present during the Week 12 assessment and also during the follow-up.

CONCLUSIONS

Self-administered rehabilitation using the SEM Glove is effective for improving and retaining gross and fine hand motor function for people living with chronic spinal cord injury at home. Retention of improved hand function suggests that an intensive activity-based rehabilitation programme in specific individuals is sufficient to improve long-term neuromuscular activity. Future studies should characterise the neuromuscular mechanism of action and the minimal rehabilitation programme necessary with the assistive device to improve ADL tasks following chronic cervical SCI.

TRIAL REGISTRATION NUMBER

Trial registration: ISRCTN, ISRCTN98677526, Registered 01/June/2017 - Retrospectively registered, http://www.isrctn.com/ISRCTN98677526.

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

Background

Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs).

Methods

The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs.

Results

The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs.

Conclusion

The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.

Effectiveness of interventions to improve hand motor function in individuals with moderate to severe stroke: a systematic review protocol

INTRODUCTION

The human hand is extremely involved in our daily lives. However, the rehabilitation of hand function after stroke can be rather difficult due to the complexity of hand structure and function, as well as neural basis that supports hand function. Specifically, in individuals with moderate to severe impairment following a stroke, previous evidence for effective treatments that recover hand function in this population is limited, and thus has never been reviewed. With the progress of rehabilitation science and tool development, results from more and more clinical trials are now available, thereby justifying conducting a systematic review.

METHODS AND ANALYSIS

This systematic review protocol is consistent with the methodology recommended by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane handbook for systematic reviews of interventions. Electronic searches will be carried out in the PubMed, CINAHL, Physiotherapy Evidence Database and Cochrane Library databases, along with manual searches in the reference lists from included studies and published systematic reviews. The date range parameters used in searching all databases is between January 1999 and January 2019. Randomised controlled trials (RCTs) published in English, with the primary outcome focusing on hand motor function, will be included. Two reviewers will screen all retrieved titles, abstracts and full texts, perform the evaluation of the risk bias and extract all data independently. The risk of bias of the included RCTs will be evaluated by the Cochrane Collaboration's tool. A qualitative synthesis will be provided in text and table, to summarise the main results of the selected publications. A meta-analysis will be considered if there is sufficient homogeneity across outcomes. The quality of the included publications will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation system from the Cochrane Handbook for Systematic Reviews of Interventions.

ETHICS AND DISSEMINATION

No ethical approval is needed, and the results of this review will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

CRD42019128285.

A Modified Reach-to-Grasp Task in a Supine Position Shows Coordination Between Elbow and Hand Movements After Stroke

Objective: A modified reach-to-grasp task has been developed for the purpose of investigating arm-hand coordination in a supine position in the functional magnetic resonance imaging environment. The objective of this study was to investigate the kinematics of the reach-to-grasp task, in stroke and healthy participants.

Design: Observational cohort study.

Setting: Movement laboratory.

Participants: Ten stroke participants and 10 age-matched healthy participants performed 10 repetitions of the modified reach-to-grasp task in two conditions—a natural condition and a standardized condition in a splint.

Intervention: Not applicable.

Main Outcome Measures: Kinematic variables of start time of transport, start time of aperture, movement duration, time of peak velocity (PV), percentage time of PV, peak deceleration (PD), percentage time of PD, peak aperture (PA), time of PA, and percentage time of PA were recorded. The correlation between key events in the grasp and transport trajectories were investigated. Performance between conditions and groups were compared.

Results: Both groups demonstrated a significant correlation between the start time of aperture and the start time of transport and between the time of PA and PV in both conditions. A significant correlation was found between the time of PA and the PD in both conditions for the healthy group, but in neither condition for the stroke group. Movements by participants with stroke had a significantly longer movement duration, a smaller PV, and an earlier absolute time of PV and PD, and an earlier percentage time of PV and PD. They also had a smaller aperture than healthy participants. Wearing the splint resulted in a significantly higher PV, later absolute and percentage time of PV, PD, and PA, and a smaller PA compared to moving without the splint. The timing of transport variables time to peak velocity and time to peak deceleration, were strongest determinants of movement duration.

Conclusion: The modified reach-to-grasp movement performed without the constraint of the splint, demonstrates similar motor control and coordination between the grasp and transport components of reach-to-grasp as in seated reach-to-grasp. This provides a new task that may be used to explore reach-to-grasp in the fMRI environment.

Investigating the feasibility and acceptability of real-time visual feedback in reducing compensatory motions during self-administered stroke rehabilitation exercises: A pilot study with chronic stroke survivors

INTRODUCTION

Homework-based rehabilitation programs can help stroke survivors restore upper extremity function. However, compensatory motions can develop without therapist supervision, leading to sub-optimal recovery. We developed a visual feedback system using a live video feed or an avatar reflecting users' movements so users are aware of compensations. This pilot study aimed to evaluate validity (how well the avatar characterizes different types of compensations) and acceptability of the system.

METHODS

Ten participants with chronic stroke performed upper-extremity exercises under three feedback conditions: none, video, and avatar. Validity was evaluated by comparing agreement on compensations annotated using video and avatar images. A usability survey was administered to participants after the experiment to obtain information on acceptability.

RESULTS

There was substantial agreement between video and avatar images for shoulder elevation and hip extension (Cohen's κ: 0.6-0.8) and almost perfect agreement for trunk rotation and flexion (κ: 0.80-1). Acceptability was low due to lack of corrective prompts and occasional noise with the avatar display. Most participants suggested that an automatic compensation detection feature with visual and auditory cuing would improve the system.

CONCLUSION

The avatar characterized four types of compensations well. Future work will involve increasing sensitivity for shoulder elevation and implementing a method to detect compensations.

"Remind-to-Move" for Promoting Upper Extremity Recovery Using Wearable Devices in Subacute Stroke: A Multi-Center Randomized Controlled Study

This paper examined the effects of "Remind-to-Move" (RTM) via vibration cueing using wearable devices to increase the use of the affected upper limb and integrate upper limb activities undertaken at home in patients with subacute stroke after inpatient discharge. In a multi-centered randomized controlled trial, 84 eligible patients from four general hospitals, who had a first stroke in the last six months, were randomly allocated to either an experimental, sham, or control group, stratified by arm function levels. Patients in the experimental group were treated by RTM, using wearable devices for three consecutive hours daily, over four weeks. The sham group used sham devices, and the control group received usual care alone. A masked assessor evaluated the patients at 0th, 4th, 8th, and 12th weeks using outcome measures included arm function tests, motor activity log, and movement recorded by the devices. Results showed that there was a significant group by time interaction, and the average movement amount and Action Research Arm Test score in the experimental group were significantly higher than in the sham group. This paper demonstrates that RTM via wearable devices used for the hemiplegic upper extremities could promote more arm recovery than the sham or control and, hence, produce an optimal functional improvement for subacute stroke patients.

Evaluation of an intervention programme addressing ability to perform activities of daily living among persons with chronic conditions: study protocol for a feasibility trial (ABLE)

INTRODUCTION

The number of persons living with a chronic condition is increasing worldwide. Conditions are considered chronic when lasting 1 year or more and requiring ongoing medical attention and/or limiting activities of daily living (ADL). Besides medical treatment, physical exercise to improve body functions is recommended and prescribed. However, improvements in body functions do not necessarily improve ability to perform ADL. Thus, it is necessary to develop interventions aiming directly at enhancing ADL ability. As a part of the research programme 'A Better Everyday Life', the first version of the ABLE intervention programme was developed.

METHODS AND ANALYSIS

This feasibility study examine the perceived value and acceptability of the ABLE programme by evaluating the fidelity, reach, dose and potential outcomes using a pretest and post-test design involving 30 persons living with chronic conditions. Qualitative interviews among occupational therapists delivering and participants receiving the ABLE programme will be conducted to explore aspects affecting the intervention.

ETHICS AND DISSEMINATION

The results will form the base for refinement of the ABLE programme and planning of a large-scale randomised controlled trial investigating the effect of the programme on self-reported and observed ADL ability. Dissemination will include peer-reviewed publications and presentations at national and international conferences.

PROTOCOL VERSION

7 November 2017: v ersion 1.0. 19 February 2018: v ersion 2.0.

TRIAL REGISTRATION NUMBER

NCT03335709; Pre-results.

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

Domiciliary VR-Based Therapy for Functional Recovery and Cortical Reorganization: Randomized Controlled Trial in Participants at the Chronic Stage Post Stroke

Background

Most stroke survivors continue to experience motor impairments even after hospital discharge. Virtual reality-based techniques have shown potential for rehabilitative training of these motor impairments. Here we assess the impact of at-home VR-based motor training on functional motor recovery, corticospinal excitability and cortical reorganization.

Objective

The aim of this study was to identify the effects of home-based VR-based motor rehabilitation on (1) cortical reorganization, (2) corticospinal tract, and (3) functional recovery after stroke in comparison to home-based occupational therapy.

Methods

We conducted a parallel-group, controlled trial to compare the effectiveness of domiciliary VR-based therapy with occupational therapy in inducing motor recovery of the upper extremities. A total of 35 participants with chronic stroke underwent 3 weeks of home-based treatment. A group of subjects was trained using a VR-based system for motor rehabilitation, while the control group followed a conventional therapy. Motor function was evaluated at baseline, after the intervention, and at 12-weeks follow-up. In a subgroup of subjects, we used Navigated Brain Stimulation (NBS) procedures to measure the effect of the interventions on corticospinal excitability and cortical reorganization.

Results

Results from the system’s recordings and clinical evaluation showed significantly greater functional recovery for the experimental group when compared with the control group (1.53, SD 2.4 in Chedoke Arm and Hand Activity Inventory). However, functional improvements did not reach clinical significance. After the therapy, physiological measures obtained from a subgroup of subjects revealed an increased corticospinal excitability for distal muscles driven by the pathological hemisphere, that is, abductor pollicis brevis. We also observed a displacement of the centroid of the cortical map for each tested muscle in the damaged hemisphere, which strongly correlated with improvements in clinical scales.

Conclusions

These findings suggest that, in chronic stages, remote delivery of customized VR-based motor training promotes functional gains that are accompanied by neuroplastic changes.

Trial Registration

International Standard Randomized Controlled Trial Number NCT02699398 (Archived by ClinicalTrials.gov at https://clinicaltrials.gov/ct2/show/NCT02699398?term=NCT02699398&rank=1)

Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care

PURPOSE OF REVIEW

Rehabilitation trials and postacute care to lessen impairments and disability after stroke, spinal cord injury, and traumatic brain injury almost never include training to promote long-term self-management of skills practice, strengthening and fitness. Without behavioral training to develop self-efficacy, clinical trials, and home-based therapy may fail to show robust results.

RECENT FINDINGS

Behavioral theories about self-management and self-efficacy for physical activity have been successfully incorporated into interventions for chronic diseases, but rarely for neurologic rehabilitation. The elements of behavioral training include education about the effects of practice and exercise that are relevant to the person, goal setting, identification of possible barriers, problem solving, feedback about performance, tailored instruction, decision making, and ongoing personal or social support. Mobile health and telerehabilitation technologies offer new ways to remotely enable such training by monitoring activity from wearable wireless sensors and instrumented exercise devices to allow real-world feedback, goal setting, and instruction.

SUMMARY

Motivation, sense of responsibility, and confidence to practice and exercise in the home can be trained to increase adherence to skills practice and exercise both during and after formal rehabilitation. To optimize motor learning and improve long-term outcomes, self-management training should be an explicit component of rehabilitation care and clinical trials.

Task-specific reach-to-grasp training after stroke: development and description of a home-based intervention

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is to transparently describe the process of developing a complex intervention for people after stroke as part of a feasibility randomised controlled trial.

Objective:

To describe and justify the development of a home-based, task-specific upper limb training intervention to improve reach-to-grasp after stroke and pilot it for feasibility and acceptability prior to a randomized controlled trial.

Intervention description:

The intervention is based on intensive practice of whole reach-to-grasp tasks and part-practice of essential reach-to-grasp components. A ‘pilot’ manual of activities covering the domains of self-care, leisure and productivity was developed for the feasibility study. The intervention comprises 14 hours of therapist-delivered sessions over six weeks, with additional self-practice recommended for 42 hours (i.e. one hour every day). As part of a feasibility randomized controlled trial, 24 people with a wide range of upper limb impairment after stroke experienced the intervention to test adherence and acceptability. The median number of repetitions in one-hour therapist-delivered sessions was 157 (interquartile range IQR 96–211). The amount of self-practice was poorly documented. Where recorded, the median amount of practice was 30 minutes (interquartile range 22–45) per day. Findings demonstrated that the majority of participants found the intensity, content and level of difficulty of the intervention acceptable, and the programme to be beneficial. Comments on the content and presentation of the self-practice material were incorporated in a revised ‘final’ intervention manual.

Discussion:

A comprehensive training intervention to improve reach-to-grasp for people living at home after stroke has been described in accordance with the Template for Intervention Description and Replication (TIDieR) reporting guidelines. The intervention has been piloted, and found to be acceptable and feasible in the home setting.

Trial registration:

ISRCTN56716589

The use and effect of video game design theory in the creation of game-based systems for upper limb stroke rehabilitation

Upper limb exercise is often neglected during post-stroke rehabilitation. Video games have been shown to be useful in providing environments in which patients can practise repetitive, functionally meaningful movements, and in inducing neuroplasticity. The design of video games is often focused upon a number of fundamental principles, such as reward, goals, challenge and the concept of meaningful play, and these same principles are important in the design of games for rehabilitation. Further to this, there have been several attempts for the strengthening of the relationship between commercial game design and rehabilitative game design, the former providing insight into factors that can increase motivation and engagement with the latter. In this article, we present an overview of various game design principles and the theoretical grounding behind their presence, in addition to attempts made to utilise these principles in the creation of upper limb stroke rehabilitation systems and the outcomes of their use. We also present research aiming to move the collaborative efforts of designers and therapists towards a model for the structured design of these games and the various steps taken concerning the theoretical classification and mapping of game design concepts with intended cognitive and motor outcomes.

H-GRASP: the feasibility of an upper limb home exercise program monitored by phone for individuals post stroke

PURPOSE

To investigate the feasibility of a phone-monitored home exercise program for the upper limb following stroke.

METHODS

A pre-post double baseline repeated measures design was used. Participants completed an 8-week home exercise program that included behavioural strategies to promote greater use of the affected upper limb. Participants were monitored weekly by therapists over the phone. The following feasibility outcomes were collected: Process (e.g. recruitment rate); Resources (e.g. exercise adherence rate); Management (e.g. therapist monitoring) and Scientific (e.g. safety, effect sizes). Clinical outcomes included: The Chedoke Arm and Hand Inventory, Motor Activity Log, grip strength and the Canadian Occupational Performance Measure.

RESULTS

Eight individuals with stroke were recruited and six participants completed the exercise program. All but one of the six participants met the exercise target of 60 minutes/day, 6 days/week. Participants were stable across the baseline period. The following post-treatment effect sizes were observed: CAHAI (0.944, p = 0.046); MALQ (0.789, p = 0.03) grip strength (0.947, p = 0.046); COPM (0.789, p = 0.03). Improvements were maintained at three and six month follow ups.

CONCLUSIONS

Community dwelling individuals with stroke may benefit from a phone-monitored upper limb home exercise program that includes behavioural strategies that promote transfer of exercise gains into daily upper limb use. Implications for Rehabilitation A repetitive, task-oriented home exercise program that utilizes telephone supervision may be an effective method for the treatment of the upper limb following stroke This program is best suited for individuals with mild to moderate level impairment and experience a sufficient level of challenge from the exercises An exercise program that includes behavioural strategies may promote transfer of exercise gains into greater use of the affected upper limb during daily activities.

Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke

Background

Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke.

Methods

A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up.

Results

Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log.

Conclusions

Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings.

Trial registration

This study has been registered at the Netherlands Trial Registry (NTR): NTR3669.

An assessment of randomized controlled trials (RCTs) for non-communicable diseases (NCDs): more and higher quality research is required in less developed countries

Research is crucial to implement evidence-based health interventions for control of non-communicable diseases (NCDs). This study aims to assess main features of randomized controlled trials (RCTs) for control of NCDs, and to identify gaps in clinical research on NCDs between high-income and less developed countries. The study included 1177 RCTs in 82 Cochrane Systematic reviews (CSRs) and evaluated interventions for adults with hypertension, diabetes, stroke, or heart diseases. Multivariate logistic regression analyses were conducted to explore factors associated with risk of bias in included RCTs. We found that 78.2% of RCTs of interventions for major NCDs recruited patients in high-income countries. The number of RCTs included in the CSRs was increasing over time, and the increasing speed was more noticeable for RCTs conducted in middle-income countries. RCTs conducted in less developed countries tended to be more recently published, less likely to be published in English, with smaller sample sizes, and at a higher risk of bias. In conclusion, there is still a lack of research evidence for control of NCDs in less developed countries. To brace for rising NCDs and avoid waste of scarce research resources, not only more but also higher quality clinical trials are required in low-and-middle-income countries.

Home-based Computer Assisted Arm Rehabilitation (hCAAR) robotic device for upper limb exercise after stroke: results of a feasibility study in home setting

Background

Home-based robotic technologies may offer the possibility of self-directed upper limb exercise after stroke as a means of increasing the intensity of rehabilitation treatment. The current literature has a paucity of robotic devices that have been tested in a home environment. The aim of this research project was to evaluate a robotic device Home-based Computer Assisted Arm Rehabilitation (hCAAR) that can be used independently at home by stroke survivors with upper limb weakness.

Methods

hCAAR device comprises of a joystick handle moved by the weak upper limb to perform tasks on the computer screen. The device provides assistance to the movements depending on users ability. Nineteen participants (stroke survivors with upper limb weakness) were recruited. Outcome measures performed at baseline (A0), at end of 8-weeks of hCAAR use (A1) and 1 month after end of hCAAR use (A2) were: Optotrak kinematic variables, Fugl Meyer Upper Extremity motor subscale (FM-UE), Action Research Arm Test (ARAT), Medical Research Council (MRC) and Modified Ashworth Scale (MAS), Chedoke Arm and Hand Activity Inventory (CAHAI) and ABILHAND.

Results

Two participants were unable to use hCAAR: one due to severe paresis and the other due to personal problems. The remaining 17 participants were able to use the device independently in their home setting. No serious adverse events were reported. The median usage time was 433 minutes (IQR 250 – 791 min). A statistically significant improvement was observed in the kinematic and clinical outcomes at A1. The median gain in the scores at A1 were by: movement time 19%, path length 15% and jerk 19%, FM-UE 1 point, total MAS 1.5 point, total MRC 2 points, ARAT 3 points, CAHAI 5.5 points and ABILHAND 3 points. Three participants showed clinically significant improvement in all the clinical outcomes.

Conclusions

The hCAAR feasibility study is the first clinical study of its kind reported in the current literature; in this study, 17 participants used the robotic device independently for eight weeks in their own homes with minimal supervision from healthcare professionals. Statistically significant improvements were observed in the kinematic and clinical outcomes in the study.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-163) contains supplementary material, which is available to authorized users.

Interventions for improving upper limb function after stroke

BACKGROUND

Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

OBJECTIVES

To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

METHODS

SEARCH METHODS

We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

SELECTION CRITERIA

We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

DATA COLLECTION AND ANALYSIS

Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

MAIN RESULTS

Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

AUTHORS' CONCLUSIONS

Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

Machine-Based, Self-guided Home Therapy for Individuals With Severe Arm Impairment After Stroke: A Randomized Controlled Trial

BACKGROUND

Few therapeutic options exist for the millions of persons living with severe arm impairment after stroke to increase their dose of arm rehabilitation. This study compared self-guided, high-repetition home therapy with a mechanical device (the resonating arm exerciser [RAE]) to conventional therapy in patients with chronic stroke and explored RAE use for patients with subacute stroke.

METHODS

A total of 16 participants with severe upper-extremity impairment (mean Fugl-Meyer [FM] score = 21.4 ± 8.8 out of 66) >6 months poststroke were randomized to 3 weeks of exercise with the RAE or conventional exercises. The primary outcome measure was FM score 1 month posttherapy. Secondary outcome measures included Motor Activity Log, Visual Analog Pain Scale, and Ashworth Spasticity Scale. After a 1-month break, individuals in the conventional group also received a 3-week course of RAE therapy.

RESULTS

The change in FM score was significant in both the RAE and conventional groups after training (2.6 ± 1.4 and 3.4 ± 2.4, P = .008 and .016, respectively). These improvements were not significant at 1 month. Exercise with the RAE led to significantly greater improvements in distal FM score than conventional therapy at the 1-month follow-up (P = .02). In a separate cohort of patients with subacute stroke, the RAE was found feasible for exercise.

DISCUSSION

In those with severe arm impairment after chronic stroke, home-based training with the RAE was feasible and significantly reduced impairment without increasing pain or spasticity. Gains with the RAE were comparable to those found with conventional training and also included distal arm improvement.

Design, development and deployment of a hand/wrist exoskeleton for home-based rehabilitation after stroke - SCRIPT project

Changes in world-wide population trends have provided new demands for new technologies in areas such as care and rehabilitation. Recent developments in the the field of robotics for neurorehabilitation have shown a range of evidence regarding usefulness of these technologies as a tool to augment traditional physiotherapy. Part of the appeal for these technologies is the possibility to place a rehabilitative tool in one's home, providing a chance for more frequent and accessible technologies for empowering individuals to be in charge of their therapy.

Objective:this manuscript introduces the Supervised Care and Rehabilitation Involving Personal Tele-robotics (SCRIPT) project. The main goal is to demonstrate design and development steps involved in a complex intervention, while examining feasibility of using an instrumented orthotic device for home-based rehabilitation after stroke.

Methods:the project uses a user-centred design methodology to develop a hand/wrist rehabilitation device for home-based therapy after stroke. The patient benefits from a dedicated user interface that allows them to receive feedback on exercise as well as communicating with the health-care professional. The health-care professional is able to use a dedicated interface to send/receive communications and remote-manage patient's exercise routine using provided performance benchmarks. Patients were involved in a feasibility study (n=23) and were instructed to use the device and its interactive games for 180 min per week, around 30 min per day, for a period of 6 weeks, with a 2-months follow up. At the time of this study, only 12 of these patients have finished their 6 weeks trial plus 2 months follow up evaluation.

Results:with the “use feasibility” as objective, our results indicate 2 patients dropping out due to technical difficulty or lack of personal interests to continue. Our frequency of use results indicate that on average, patients used the SCRIPT1 device around 14 min of self-administered therapy a day. The group average for the system usability scale was around 69% supporting system usability.

Conclusions:based on the preliminary results, it is evident that stroke patients were able to use the system in their homes. An average of 14 min a day engagement mediated via three interactive games is promising, given the chronic stage of stroke. During the 2nd year of the project, 6 additional games with more functional relevance in their interaction have been designed to allow for a more variant context for interaction with the system, thus hoping to positively influence the exercise duration. The system usability was tested and provided supporting evidence for this parameter. Additional improvements to the system are planned based on formative feedback throughout the project and during the evaluations. These include a new orthosis that allows a more active control of the amount of assistance and resistance provided, thus aiming to provide a more challenging interaction.

Retraining and assessing hand movement after stroke using the MusicGlove: comparison with conventional hand therapy and isometric grip training

BACKGROUND

It is thought that therapy should be functional, be highly repetitive, and promote afferent input to best stimulate hand motor recovery after stroke, yet patients struggle to access such therapy. We developed the MusicGlove, an instrumented glove that requires the user to practice gripping-like movements and thumb-finger opposition to play a highly engaging, music-based, video game. The purpose of this study was to 1) compare the effect of training with MusicGlove to conventional hand therapy 2) determine if MusicGlove training was more effective than a matched form of isometric hand movement training; and 3) determine if MusicGlove game scores predict clinical outcomes.

METHODS

12 chronic stroke survivors with moderate hemiparesis were randomly assigned to receive MusicGlove, isometric, and conventional hand therapy in a within-subjects design. Each subject participated in six one-hour treatment sessions three times per week for two weeks, for each training type, for a total of 18 treatment sessions. A blinded rater assessed hand impairment before and after each training type and at one-month follow-up including the Box and Blocks (B & B) test as the primary outcome measure. Subjects also completed the Intrinsic Motivation Inventory (IMI).

RESULTS

Subjects improved hand function related to grasping small objects more after MusicGlove compared to conventional training, as measured by the B & B score (improvement of 3.21±3.82 vs. -0.29±2.27 blocks; P=0.010) and the 9 Hole Peg test (improvement of 2.14±2.98 vs. -0.85±1.29 pegs/minute; P=0.005). There was no significant difference between training types in the broader assessment batteries of hand function. Subjects benefited less from isometric therapy than MusicGlove training, but the difference was not significant (P>0.09). Subjects sustained improvements in hand function at a one month follow-up, and found the MusicGlove more motivating than the other two therapies, as measured by the IMI. MusicGlove games scores correlated strongly with the B & B score.

CONCLUSIONS

These results support the hypothesis that hand therapy that is engaging, incorporates high numbers of repetitions of gripping and thumb-finger opposition movements, and promotes afferent input is a promising approach to improving an individual's ability to manipulate small objects. The MusicGlove provides a simple way to access such therapy.

Home-based reach-to-grasp training for people after stroke: study protocol for a feasibility randomized controlled trial

BACKGROUND

This feasibility study is intended to assess the acceptability of home-based task-specific reach-to-grasp (RTG) training for people with stroke, and to gather data to inform recruitment, retention, and sample size for a definitive randomized controlled trial.

METHODS/DESIGN

This is to be a randomized controlled feasibility trial recruiting 50 individuals with upper-limb motor impairment after stroke. Participants will be recruited after discharge from hospital and up to 12 months post-stroke from hospital stroke services and community therapy-provider services. Participants will be assessed at baseline, and then electronically randomized and allocated to group by minimization, based on the time post-stroke and extent of upper-limb impairment. The intervention group will receive 14 training sessions, each 1 hour long, with a physiotherapist over 6 weeks and will be encouraged to practice independently for 1 hour/day to give a total of 56 hours of training time per participant. Participants allocated to the control group will receive arm therapy in accordance with usual care. Participants will be measured at 7 weeks post-randomization, and followed-up at 3 and 6 months post-randomization. Primary outcome measures for assessment of arm function are the Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT). Secondary measures are the Motor Activity Log, Stroke Impact Scale, Carer Strain Index, and health and social care resource use. All assessments will be conducted by a trained assessor blinded to treatment allocation. Recruitment, adherence, withdrawals, adverse events (AEs), and completeness of data will be recorded and reported.

DISCUSSION

This study will determine the acceptability of the intervention, the characteristics of the population recruited, recruitment and retention rates, descriptive statistics of outcomes, and incidence of AEs. It will provide the information needed for planning a definitive trial to test home-based RTG training.

TRIAL REGISTRATION ISRCTN

ISRCTN56716589.

Home-based therapy programmes for upper limb functional recovery following stroke

BACKGROUND

With an increased focus on home-based stroke services and the undertaking of programmes, targeted at upper limb recovery within clinical practice, a systematic review of home-based therapy programmes for individuals with upper limb impairment following stroke was required.

OBJECTIVES

To determine the effects of home-based therapy programmes for upper limb recovery in patients with upper limb impairment following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group's Specialised Trials Register (May 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE (1950 to May 2011), EMBASE (1980 to May 2011), AMED (1985 to May 2011) and six additional databases. We also searched reference lists and trials registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults after stroke, where the intervention was a home-based therapy programme targeted at the upper limb, compared with placebo, or no intervention or usual care. PRIMARY OUTCOMES were performance in activities of daily living (ADL) and functional movement of the upper limb. SECONDARY OUTCOMES were performance in extended ADL and motor impairment of the arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts, extracted data and appraised trials. We undertook assessment of risk of bias in terms of method of randomisation and allocation concealment (selection bias), blinding of outcome assessment (detection bias), whether all the randomised patients were accounted for in the analysis (attrition bias) and the presence of selective outcome reporting.

MAIN RESULTS

We included four studies with 166 participants. No studies compared the effects of home-based upper limb therapy programmes with placebo or no intervention. Three studies compared the effects of home-based upper limb therapy programmes with usual care.

PRIMARY OUTCOMES

we found no statistically significant result for performance of ADL (mean difference (MD) 2.85; 95% confidence interval (CI) -1.43 to 7.14) or functional movement of the upper limb (MD 2.25; 95% CI -0.24 to 4.73)).

SECONDARY OUTCOMES

no statistically significant results for extended ADL (MD 0.83; 95% CI -0.51 to 2.17)) or upper limb motor impairment (MD 1.46; 95% CI -0.58 to 3.51). One study compared the effects of a home-based upper limb programme with the same upper limb programme based in hospital, measuring upper limb motor impairment only; we found no statistically significant difference between groups (MD 0.60; 95% CI -8.94 to 10.14).

AUTHORS' CONCLUSIONS

There is insufficient good quality evidence to make recommendations about the relative effect of home-based therapy programmes compared with placebo, no intervention or usual care.